The discharge diagnosis must include at least one of the following: hypertension, type 2 diabetes, chronic obstructive pulmonary disease, or osteoporosis, and be accompanied by other chronic diseases (with a total of at least two comorbidities).
Conditions
Interventions
control group:Routine care
Intervention group:Multicomponent Transitional Medication Safety Program
Sponsors
Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
Eligibility
Sex/Gender
All
Age
60 Years to No maximum
Inclusion criteria
Inclusion criteria: 1.Age >= 60 years; 2.Discharge diagnosis includes at least one of the following: hypertension, type 2 diabetes, chronic obstructive pulmonary disease, or osteoporosis, with at least one other co-existing chronic condition (total comorbidities >=2); 3.Number of chronic medications at discharge >=5, excluding temporary orders, pro re nata medications, and short-term courses like antibiotics; 4.At least one change to a chronic medication during hospitalization (including addition, discontinuation, dose adjustment, or substitution); 5.Voluntarily enrolled with a primary care team and able to participate in telephone/home follow-up;
Exclusion criteria
Exclusion criteria: 1.Presence of significant communication barriers, cognitive impairment, severe memory deficits, or psychiatric disorders that would affect intervention adherence or the validity of assessments; 2.Diagnosis of a terminal or severe organic disease (e.g., advanced heart failure, end-stage renal disease, active malignancy) with a life expectancy of <6 months; 3.Concurrent participation in another interventional clinical trial;
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Proportion of patients with at least one medication-related problem(MRP) and mean MRP rate per patient; | — |
Secondary
| Measure | Time frame |
|---|---|
| Distribution of MRP quantities and types;Unplanned readmission (all-cause);Emergency department visit;Medication?related readmission or emergency department visit;All?cause mortality;Patient knowledge of medication regimen (recall accuracy);Patient satisfaction with pharmaceutical services;Health-related quality of life;Teach-back completion rate;Completion rate of community follow-up;Quality of discharge medication summary;Number and types of interventions by family physician team;Timeliness of receipt of discharge medication summary;Medication adherence;Implementation of medication reconciliation; | — |
Countries
China
Contacts
Public ContactYou Ruxu
Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
Outcome results
None listed